Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant View Nursing Center during CMS and state inspections, most recent first.
The facility did not conduct complete investigations into multiple abuse allegations, including failing to interview involved residents and witnesses as required by policy. In several cases, such as when a resident reported being hit, another alleged inappropriate physical contact, and a hospital social worker raised concerns about bruising, the facility did not document or perform thorough investigations. The Administrator confirmed these investigative steps were missed.
A resident was found to have bruising by a hospital Social Worker, who notified the facility's DON. The DON explained the bruising as resulting from a fall out of a wheelchair, but the facility did not notify the SSA of the physical abuse allegation as required by policy. The Administrator confirmed the incident was not reported.
The facility failed to maintain sanitary conditions for three garbage dumpsters, leading to trash spilling onto the ground and exposure of fecal matter. The issue arose due to nonpayment of the trash service bill, resulting in missed trash pickups. The Maintenance Director informed the Administrator, but no specific instructions were given to address the situation. The Administrator was unaware of the extent of the issue and believed the payment problem had been resolved.
The facility failed to maintain safe water temperatures in resident bathrooms and shower rooms, with temperatures exceeding recommended levels, posing risks of burns and scalds. Additionally, a shower room contained environmental hazards, including a plugged-in hair dryer and unsecured isopropyl alcohol, creating potential accident risks. The facility's policies on water safety and environmental hazards were not effectively implemented, leading to these deficiencies.
A medication cart was found unlocked and unattended on two occasions, contrary to the facility's policy requiring carts to be locked unless under a nurse's supervision. Staff interviews confirmed the oversight, with one nurse attributing the lapse to being distracted by an emergency situation.
The facility failed to follow infection control practices during a glucometer check, with an LPN not using a barrier for supplies. Additionally, washbasins and urinals were improperly stored, and linen handling policies were not followed, leading to potential cross-contamination. Sharps containers were overfilled, posing biohazard risks.
A resident's urinary catheter drainage bag was not covered with a privacy bag, compromising their dignity. Observations showed the bag was uncovered as the resident walked in the hallway. Interviews with the DON, CNA, and Administrator confirmed the need for coverage, but no policy was provided.
Two residents were found with unauthorized medications at their bedsides, including an albuterol inhaler and alcohol-containing mouthwash, despite not being assessed or approved for self-administration. The facility staff were unaware of these medications, indicating a lapse in monitoring.
The facility failed to conduct pre-employment screenings, including reference checks and fingerprinting, for four employees. The Director of Human Resources cited being busy as the reason for not completing these checks, while the Administrator was unaware of the oversight. This deficiency posed a potential risk to residents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with dementia did not have a fall mat as required, while two residents with respiratory conditions received incorrect oxygen flow rates. Staff interviews revealed a lack of adherence to care plans.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. One resident did not receive ordered therapy evaluations for a hand contracture, while another resident's gastrostomy tube water flushes were not documented as required. Staff interviews confirmed the lapses in following and documenting physician orders.
A resident with a contracture of the left hand did not receive necessary ROM services due to a lack of therapy evaluations and specific care instructions. Despite physician orders for therapy evaluations, the care plan did not include ROM exercises, and the contracture was not noted in the CNA Plan of Care. Observations and staff interviews confirmed the absence of ROM exercises, and the resident was not using a splint device.
Two residents receiving oxygen therapy were administered oxygen at 2.5 LPM instead of the prescribed 2.0 LPM, potentially increasing the risk of respiratory complications. Despite physician orders, staff failed to monitor and adjust the oxygen settings correctly. Interviews with staff, including an LPN, the Unit Manager, and the DON, confirmed the oversight, with the Unit Manager adjusting the oxygen to the correct level upon discovery.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple allegations of abuse involving six residents out of a sample of twenty-two. According to the facility's own policy, all alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect are to be thoroughly investigated, including immediate investigation and interviews with the resident or other witnesses. However, in several cases, such as when a resident called the police alleging theft and inappropriate touching by other residents, and when another resident reported being hit in the chest by a male friend, the facility did not conduct additional resident interviews as required. The Administrator confirmed that these interviews were not performed during the investigations. Further review revealed additional failures to investigate allegations. In one instance, a resident alleged that another resident put a hand around her neck while removing a smoking apron, and although staff intervened and separated the residents, there was no evidence of a comprehensive investigation. In another case, a hospital social worker reported concerns about bruises on a resident's body after a fall, but there was no documentation that this allegation was investigated. The Administrator acknowledged awareness of the report but confirmed that no investigation was conducted. These actions and inactions demonstrate a pattern of incomplete abuse investigations, contrary to facility policy.
Failure to Report Allegation of Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse involving one resident. According to the facility's policy, all employees are required to immediately notify administrative staff and the SSA of any complaint or allegation of resident abuse as soon as the facility becomes aware. In this case, the Director of Nursing (DON) was informed by a hospital Social Worker about concerns regarding bruising observed on a resident's body. The Social Worker communicated that the bruises were noted during the resident's hospital stay, and the DON explained that the resident had previously fallen forward out of his wheelchair due to a tendency to lean forward. Despite being made aware of the bruising and the concern raised by the hospital Social Worker, there was no documentation that the SSA was notified of this allegation of physical abuse. The Administrator confirmed during an interview that the call from the hospital Social Worker was known and acknowledged that the incident was not reported to the SSA as required by facility policy.
Unsanitary Conditions of Garbage Dumpsters
Penalty
Summary
The facility failed to maintain three garbage dumpsters in sanitary conditions, as observed by surveyors. Trash was piled high and spilling over onto the ground, with opened bags exposing dirty briefs with fecal matter and wipes covered in feces scattered around the dumpsters. Swarms of flies were present, and at least 50 large clear white trash bags containing food, trash, and soiled personal care items were observed on the ground. The Dietary Manager and Maintenance Director confirmed the unsanitary conditions and reported that the issue had persisted since the previous Monday due to insufficient space in the dumpsters. The Maintenance Director revealed that the trash was not picked up because the facility had not paid the trash service bill. He informed the Administrator of the issue on 8/13/2024, but no specific instructions were given on how to handle the trash pile-up. The Administrator confirmed the unsanitary conditions and acknowledged the lack of guidance provided to staff. He stated that the corporate office was notified about the payment issue on 8/14/2024 and believed the bill had been paid. The Administrator was unaware of the trash spilling onto the ground and stated he would have addressed it if informed.
Unsafe Water Temperatures and Environmental Hazards in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures in 12 of 28 resident bathrooms and two of three resident shower rooms, as observed by surveyors. The water temperatures in these areas were found to be higher than the recommended levels, with temperatures ranging from 110.3 to 123 degrees Fahrenheit. The Maintenance Director admitted to checking water temperatures daily but acknowledged that the temperatures were not consistently maintained at the recommended levels. The facility's policy on water temperatures was not effectively implemented, leading to potential risks of burns and scalds for residents. Additionally, the facility did not ensure an environment free from chemical and environmental hazards in one of the shower rooms. Observations revealed a cart containing a bottle of 70 percent isopropyl alcohol and a plugged-in hair dryer, along with various items scattered on the floor, creating potential accident hazards. The Administrator and Maintenance Director confirmed these findings and acknowledged the unacceptable condition of the shower room, which posed numerous risks to residents. The facility's failure to adhere to its policies on maintaining safe water temperatures and preventing environmental hazards in resident areas resulted in a deficient practice. The lack of a policy on environmental hazards further contributed to the unsafe conditions observed in the shower room, placing residents at risk of avoidable injuries and a diminished quality of life.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse, as required by their policy titled 'Medication Administration Guidelines.' This policy, dated August 2021, mandates that medication carts must be kept locked at all times unless under the direct supervision of a licensed nurse. During observations on August 18, 2024, the surveyor noted that Medication Cart 2 was left unattended and unlocked in the hallway on two separate occasions. In the first instance, the cart was left open from 12:15 pm to 12:21 pm until RN JJ approached and locked it. Later that day, at 6:41 pm, the same cart was again found unattended and unlocked until LPN II noticed the surveyor's presence and secured it. Interviews conducted with the nursing staff confirmed the oversight. RN JJ acknowledged that the cart was unlocked during her shift without a nurse present. LPN II admitted to leaving the cart open earlier in the shift, attributing the lapse to being preoccupied with a resident who was transported to the emergency room. Further interviews with the Unit Manager and the Director of Nursing reiterated the expectation that medication carts should always be locked unless a nurse is actively administering medications. The failure to adhere to this policy posed a potential risk of unauthorized access to medications by residents or visitors.
Infection Control Deficiencies in Glucometer Use and Linen Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during a glucometer check for a resident. An LPN was observed performing a fingerstick blood sugar test without using a barrier on the cart where supplies were placed, both before and after the procedure. This was confirmed by the LPN, the Unit Manager, and the Director of Nursing, who all acknowledged that a barrier should have been used to prevent cross-contamination. Additionally, the facility did not properly store personal care items such as washbasins and urinals in resident restrooms. Observations revealed that these items were unbagged and unlabeled, which was confirmed by the Director of Nursing as not meeting the facility's standards. This lack of proper labeling and storage could lead to cross-contamination among residents. The facility also failed to follow its own policies regarding the storage and handling of linen and biohazardous waste. Observations showed that clean linen was uncovered and exposed, and soiled linen was improperly stored in shower rooms. Furthermore, sharps containers were found to be overfilled, with exposed razors, indicating a failure to manage biohazardous waste correctly. These issues were acknowledged by the facility's staff, including the Administrator and the Infection Control Preventionist, as potential infection control concerns.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R251, by not covering the resident's indwelling urinary catheter drainage bag with a privacy bag. This deficiency was observed on two occasions, where the drainage bag was uncovered and visible as the resident walked down a hallway. The resident was admitted to the facility with a urinary catheter due to urinary retention, as indicated in the care plan, but there were no interventions noted for covering the drainage bag. Interviews with the Director of Nursing, a Certified Nursing Assistant, and the Administrator confirmed that the drainage bag should have been covered for dignity purposes. Additionally, the facility was unable to provide a policy regarding the use of privacy bags for catheter drainage bags.
Unauthorized Medications Found at Residents' Bedsides
Penalty
Summary
The facility failed to ensure that two residents did not have unsecured and unauthorized medications at their bedside, which placed them at risk for inappropriate and unsafe medication use. Resident 49, diagnosed with vascular dementia and other conditions, was found with a prescription albuterol inhaler in his room, despite not being assessed or approved to self-administer medications. The inhaler was obtained from a previous medical appointment, and the resident reported using it occasionally. The Unit Manager confirmed the presence of the inhaler and was unaware of its existence in the room, indicating a lapse in monitoring resident rooms for medications. Resident 1, with severe cognitive impairment and diagnosed with dementia, schizophrenia, and bipolar disorder, was found with a bottle of mouthwash containing alcohol at the bedside. There was no assessment for self-administration of medication for this resident. The Unit Manager confirmed the unauthorized mouthwash, which was not allowed due to its alcohol content, and removed it from the room. The Director of Nursing was unaware of these unauthorized medications and highlighted the potential risks associated with their use, such as increased heart rate and adverse effects on blood pressure.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility failed to ensure that pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four out of ten employees reviewed. This deficiency was identified during a review of employee files, which revealed that a reference check was not completed for a Dietary Supervisor hired in 1998, a Certified Nursing Assistant hired in 2024, and a Dietary staff member hired in 2024. Additionally, an Activities Assistant hired in 2024 did not have a fingerprint procedure completed, despite working multiple shifts without this requirement being fulfilled. The Director of Human Resources acknowledged the missing pre-employment requirements, attributing the oversight to being very busy and not having the opportunity to call references or complete the fingerprinting process within the required timeframe. The Administrator was unaware of the missing pre-employment requirements and did not provide an explanation for the absence of this information in the employee files. This oversight had the potential to place residents at risk of abuse, neglect, and exploitation from staff.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement person-centered comprehensive care plans for three residents, leading to deficiencies in their care. One resident, diagnosed with paranoid schizophrenia, Alzheimer's disease, and vascular dementia, had a care plan that included the use of a fall mat to prevent fall-related injuries. However, observations over several days revealed that the fall mat was not placed by the resident's bedside as required. Interviews with staff, including an LPN and the Regional Director of Nursing, confirmed the absence of the fall mat and highlighted a lack of adherence to the care plan. Two other residents, both with respiratory conditions, had care plans that required specific oxygen settings. One resident with chronic obstructive pulmonary disease was observed receiving oxygen at a higher flow rate than prescribed, and staff were unaware of the care plan's requirements to monitor and adjust the oxygen settings. Similarly, another resident with acute chronic respiratory failure was also receiving oxygen at an incorrect flow rate. Interviews with the Unit Manager and MDS Coordinator revealed a lack of awareness and adherence to the care plans, resulting in the incorrect administration of oxygen.
Failure to Follow Physician Orders for Therapy and G-tube Care
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in their care. For one resident, who was admitted with a diagnosis including contracture of the left hand, there was a physician's order for evaluations for physical therapy, occupational therapy, and speech therapy. However, these evaluations were not conducted, and the resident expressed concern about not receiving therapy services for a splint device and range of motion exercises. The Unit Manager and Director of Rehabilitation confirmed that the order was not followed, and the resident did not receive the necessary therapy evaluations. For another resident with diagnoses including dysphagia and severe protein-calorie malnutrition, the facility failed to document the required gastrostomy tube water flushes as per physician's orders. The orders specified water flushes after each medication and before and after feedings, but there was no documentation of these flushes in the medication administration record or progress notes. An LPN verified that the water flushes were not documented, and the Regional Director of Nursing stated that the nurse responsible for receiving the physician's order should have transcribed it onto the medication administration record.
Failure to Provide ROM Services for Resident with Contracture
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for a resident with a contracture of the left hand. The resident, identified as R43, was admitted with a diagnosis that included contracture of the left hand. Despite having a cognitive status indicating little to no impairment, the resident did not receive physical or occupational therapy as documented in the admission Minimum Data Set. Physician orders for therapy evaluations were issued, but the care plan did not include specific instructions for ROM exercises for the left hand, and the contracture was not noted in the Certified Nursing Assistants' (CNA) Plan of Care. Observations during the survey revealed that the resident was not using a splint device, and the fingers of the left hand were folded into the palm. Interviews with the resident and staff confirmed that ROM exercises were not being provided. The CNA acknowledged awareness of the contracture but did not perform ROM exercises. The Unit Manager and Director of Rehabilitation were aware of the contracture but confirmed that no therapy evaluation had been conducted. The Director of Nursing stated that therapy recommendations are typically added to the CNA Plan of Care after evaluations, which had not occurred in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R49 and R68, which had the potential to increase the risk of respiratory complications. R49, diagnosed with chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia, had a physician order for oxygen at 2 liters per minute (LPM) at night and as needed. However, observations revealed that R49 was receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM. Similarly, R68, diagnosed with acute chronic respiratory failure with hypoxia and hypercapnia, had a physician order for oxygen at 2 LPM as needed for shortness of breath, but was also observed receiving oxygen at 2.5 LPM. Interviews with staff, including a Licensed Practical Nurse (LPN), the Unit Manager, the MDS Coordinator, and the Director of Nursing (DON), confirmed the discrepancy in oxygen administration. The LPN and Unit Manager were unaware of the incorrect oxygen settings, and the Unit Manager adjusted the oxygen to the correct level upon discovery. The MDS Coordinator noted that R49 had a history of adjusting his oxygen flow meter, and the DON emphasized the expectation for staff to ensure oxygen was administered according to physician orders. The failure to monitor and adjust the oxygen settings as prescribed placed the residents at risk for complications, particularly for R49, who was at risk of COPD exacerbation due to receiving more oxygen than ordered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Metter
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azalea Health And Rehabilitation | 0.7 mi | ★★★★★ | 8 | 0 |
| Orchard Health And Rehabilitation | 5.4 mi | ★★★★★ | 0 | 0 |
| Twin City Trails Of Journey Llc | 14.1 mi | ★★★★★ | 9 | 0 |
| Westwood Healthcare And Rehabilitation | 15.4 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Swainsboro | 15.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.